Prehospital ECG transmission results in shorter door-to-wire time for STEMI patients in a remote mountainous region.

BACKGROUND: Pre-hospital triage with ECG-transmission may reduce time to reperfusion in patients with ST-elevation acute myocardial infarction (STEMI). Less, however, is known on potential benefit of ECG-transmission triage in mountain areas, with complex orography. METHODS: Patients admitted for STEMI and primary coronary angioplasty (pPCI) in a mountain area served by a single cathlab and triaged with ECG-transmission were enrolled in the study and compared with controls: patients' demographics and time to coronary wire were recorded. RESULTS: Forty-seven consecutive patients were enrolled in the study: 23 patients following ECG transmission and 24 STEMI patients who presented directly to the Emergency Department. At multivariable regression analysis, pre-hospital ECG-transmission electrocardiogram was an independent predictor of shorter time-to-wire (beta -0.34, p < 0.05). In case of transport times >30 min, ECG-transmission triage achieved time-to-wire times 20% shorter. Excluding unreducible transport time, avoidable delay was reduced by 38% in the whole population, by 48% in case of peripheral areas (transport time > 30 min from cathlab) and elderly (>80 years) patients (p < 0.05 in all cases). CONCLUSIONS: Pre-hospital triage with ECG-transmission is associated with shorter ischemic time even in mountain areas with a complex orography profile. The benefit is greater in elderly patients and remote areas.

Shortened head-up tilting test guided by systolic pressure reductions in neurocardiogenic syncope.

BACKGROUND: Asymptomatic reductions in arterial pressure have been reported to occur before the onset of tilt-induced syncope. We investigated the predictive value of these reductions for a positive tilt result. METHODS AND RESULTS: In a first study, 238 consecutive healthy subjects with unexplained syncope underwent a passive tilt table test. Finger systolic arterial pressure (SAP) recordings made it possible to calculate how many of the beat-to-beat SAP values during the first 15 minutes of tilt were lower than the lowest value recorded at baseline. Neurocardiogenic syncope was diagnosed in 73 subjects; 28 fainted after 15 minutes of tilt and experienced more pressure reductions than did the subjects with a negative test (328+/-400 versus 119+/-284; P<0.01). More than 14 SAP reductions during the first 15 minutes of tilt allowed us to predict a positive test with 93% sensitivity, 58% specificity, and positive and negative predictive values of 28% and 98%, respectively. In a second prospective study (80 consecutive subjects), the online analysis of this criterion by visually inspecting a Finapres monitor showed 80% sensitivity, 85% specificity, and positive and negative predictive values of 57% and 94%. CONCLUSIONS: In healthy subjects with unexplained syncope, the evaluation of SAP reductions during the first 15 minutes of tilt is a marker of systolic pressure instability preceding syncope and constitutes a simple and good predictor of tilt outcome that could be used to guide test duration.

Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony.

OBJECTIVES: The value of interventricular and intraventricular echocardiographic asynchrony parameters in predicting reverse remodeling after cardiac resynchronization therapy (CRT) was investigated. BACKGROUND: Cardiac resynchronization therapy has been suggested as a promising strategy in patients with severe heart failure and left bundle branch block (LBBB), but the entity of benefit is variable and no criteria are yet available to predict which patients will gain. METHODS: Interventricular and intraventricular mechanical asynchrony was evaluated in 20 patients (8 men and 12 women, 63 +/- 10 years) with advanced heart failure caused by ischemic (n = 4) or nonischemic dilated cardiomyopathy (n = 16) and LBBB (QRS duration of at least 140 ms) using echocardiographic Doppler measurements. Left ventricular end-diastolic volume index (LVEDVI) and left ventricular end-systolic volume index (LVESVI) were calculated before and one month after CRT. Patients with a LVESVI reduction of at least 15% were considered as responders. RESULTS: Cardiac resynchronization therapy significantly improved ventricular volumes (LVEDVI from 150 +/- 53 ml/m(2) to 119 +/- 37 ml/m(2), p < 0.001; LVESVI from 116 +/- 43 ml/m(2) to 85 +/- 29 ml/m(2), p < 0.0001). At baseline, the responders had a significantly longer septal-to-posterior wall motion delay (SPWMD), a left intraventricular asynchrony parameter; only QRS duration and SPWMD significantly correlated with a reduction in LVESVI (r = -0.54, p < 0.05 and r = -0.70, p < 0.001, respectively), but the accuracy of SPWMD in predicting reverse remodeling was greater than that of the QRS duration (85% vs. 65%). CONCLUSIONS: In patients with advanced heart failure and LBBB, baseline SPWMD is a strong predictor of the occurrence of reverse remodeling after CRT, thus suggesting its usefulness in identifying patients likely to benefit from biventricular pacing.

Enhanced reflex response to baroreceptor deactivation in subjects with tilt-induced syncope.

OBJECTIVES: We sought to evaluate whether changes in resting baroreflex control of heart rate are a distinctive feature of healthy subjects with a history of syncope prone to a positive tilt-test response. BACKGROUND: The mechanisms involved in the pathogenesis of vasovagal syncope (VVS) are still poorly understood; in particular, the contribution of arterial baroreflex control of heart rate is matter of discussion. METHODS: A passive tilt-table test was performed in 312 consecutive, otherwise healthy subjects (age 36 +/- 15 years) with unexplained syncope and 100 control subjects. At baseline, spontaneous baroreflex sensitivity (BRS; ms/mm Hg) and the baroreflex effectiveness index (BEI) were assessed using the sequence method. RESULTS: The study population showed normal baroreflex function. Tilt-induced VVS in 94 subjects who were younger than both the tilt-negative and control subjects (30 +/- 14, 38 +/- 15, and 37 +/- 14 years, respectively; p = 0.00005) showed greater BRS (17.4 +/- 9.8, 13.2 +/- 7.9, and 12.8 +/- 8.2 ms/mm Hg, respectively; p = 0.0001), but had a similar BEI (0.59 +/- 0.18, 0.56 +/- 0.19, and 0.58 +/- 0.2, respectively; p = NS). On Cox multivariate analysis, the occurrence of VVS during tilt was inversely related to age (hazard ratio 0.97; p = 0.0004) and directly related to the BRS slope of sequences, implying a baroreceptor deactivation (hazard ratio 1.05; p = 0.02), but not of sequences characterized by arterial baroreceptor stimulation. CONCLUSIONS: Subjects with tilt-induced VVS showed greater resting BRS but had a normal BEI. The enhanced reflex tachycardic response to arterial baroreceptor deactivation at rest may represent a characteristic feature of subjects prone to tilt-induced VVS.

Association of beta-adrenergic receptor polymorphisms and progression to heart failure in patients with idiopathic dilated cardiomyopathy.

PURPOSE: Increased sympathetic nervous system activation via the beta-adrenergic pathway influences the evolution of idiopathic dilated cardiomyopathy. We assessed the effects of beta-adrenergic receptor variants on heart failure in idiopathic dilated cardiomyopathy. METHODS: We prospectively analyzed 171 consecutive patients (mean [+/- SD] age, 49 +/- 14 years; 129 men) with idiopathic dilated cardiomyopathy who were receiving conventional treatment. All were characterized by polymerase chain reaction-restriction fragment length polymorphism analysis for Ser49Gly and Arg389Gly in the beta1-adrenergic receptor; the 5' leader cistron (LC) Arg19Cys, Arg16Gly, Gln27Glu, and Thr164Ile in the beta2-adrenergic receptor; and Arg64Trp in the beta3-adrenergic receptor. The endpoint was heart failure, defined as a worsening of clinical condition leading to hospitalization for heart failure, cardiac transplantation, or death from heart failure. RESULTS: During a median follow-up of 33 months, 24 patients had heart failure. In a Cox univariate analysis, the beta1Gly49 and beta2 5'LC-Cys19, Arg16, and Gln27 alleles were associated with a lower risk of heart failure. In a multivariate analysis that considered age, functional class, left ventricular ejection fraction, and beta-blocker use, three beta2-adrenergic receptor alleles were associated with lower risk: 5'LC-Cys19 (hazard ratio [HR]: 0.15; 95% confidence interval [CI]: 0.05 to 0.42), Arg16 (HR: 0.12; 95% CI: 0.04 to 0.35), and Gln27 (HR: 0.15; 95% CI: 0.05 to 0.42). CONCLUSION: The Gly49 allele in the beta1-adrenergic receptor and the 5' LC-Cys19, Arg16, and Gln27 alleles in the beta2-adrenergic receptor were associated with a lower risk of heart failure in idiopathic dilated cardiomyopathy, suggesting that the beta1- and beta2-adrenergic receptor genes are modifier genes.

[Natriuretic peptides and essential arterial hypertension]. / Peptidi natriuretici e ipertensione arteriosa essenziale.

Natriuretic peptide system plays a well-defined role in the regulation of blood pressure and fluid volume. Although the effects of natriuretic peptides (atrial natriuretic peptide, brain natriuretic peptide and C-type natriuretic peptide) are mediated by specific biologic receptors, their plasma level is influenced by clearance receptors. It has been demonstrated that in hypertensive subjects plasma levels of natriuretic peptides are impaired; furthermore peptide receptor polymorphisms have been shown to be significantly associated with hypertension and cardiac hypertrophy. Studying normotensive subjects at high genetic risk of developing hypertension on the basis of family history makes it possible to investigate the role of natriuretic peptide system in the genesis of hypertension. It has been shown that plasma atrial and ventricular natriuretic peptide levels are significantly reduced in normotensive subjects with a family history of hypertension. Our study is the first one showing association among positive family history of essential hypertension and natriuretic peptide receptor polymorphisms. We identified a novel insertion/deletion polymorphism at position 15,129 in the 3'-untranslated region (3'-UTR) of NPRA receptor mRNA. The NPRA gene deletion variant is associated with hypertensive family history and higher systolic blood pressure. The "deletion 15129" variant might participate in the functional impairment of natriuretic peptide system defining an increased genetic susceptibility to hypertension.